Treatment of diabetic ketoacidosis with subcutaneous regular insulin in a non-ICU setting is effective and economical: A single-center experience

Abstract

Background: The mainstay of treatment for diabetic ketoacidosis (DKA) is the correction of dehydration and hyperglycemia with intravenous fluids and intravenous insulin (IVI). Subcutaneous insulin (SCI) has been tried in a few centers in patients with DKA if the blood pH is >7. In general, IVI is preferred over SCI or intramuscular insulin as its onset is rapid and the dose can be titrated based on patient’s varying blood glucose (BG) levels. However, IVI is associated with higher cost of hospitalizations and resource requirements. Thus, SCI could be an alternative to IVI infusion for DKA to reduce these costs and distress, in children during times of resource constraint such as the COVID-19 pandemic and in other resource-limited settings. Objective: The objective of the study was to compare the cost and efficacy of SCI therapy versus IVI infusion in the treatment of DKA. Materials and methods: A retrospective and cohort study was conducted among children aged 1–15 years admitted with DKA from 2013 to 2014 and treated with IVI and in 2017 treated with SCI at a tertiary hospital. One cohort was treated with IV infusion of regular insulin in intensive care units (ICU) and another cohort was treated with SC regular insulin in pediatric general wards. The main outcomes measured were the overall cost of hospitalization and hours to improvement in the child’s health. The data were analyzed with independent samples t-test with SPSS software. Results: Forty-eight patients admitted with 50 episodes of DKA were analyzed. Baseline characteristics of the two groups were similar in age, sex, BG, serum sodium, and HbA1C levels. The proportion of girls to boys was 13:8 (IV insulin group) and 20:9 (SC insulin group); the daily dose of insulin on day 1 of treatment was 1.2:1 unit/kg/day in IVI: SCI groups. The lowest recorded pH was 6.822 (range 6.822–7.154) and 6.831(range 6.831–7.292) in the IVI and SCI groups. The mean pH was 7.00 ± 0.10 and 7.1 ± 0.12, respectively, in IVI and SCI groups (P = 0.02). Episodes of DKA treated with IVI and SCI groups were 21 and 29, respectively. 23% of patients had severe DKA, 52% had moderate DKA, and 25% had mild DKA. The mean time for improvement in the IVI group was 34.95 ± 14.05 h and 17.23 ± 9.85 h in the SCI group (P = 0.001), respectively. The average cost of hospitalization was Rs. 53712 ± 18813 for IVI therapy and Rs. 14369 ± 5768 for SCI (P = 0.000). There were no major complications in the SCI group compared to the IVI group. Conclusion: DKA was managed effectively in general wards with SCI therapy with pH not being a limiting factor. Earlier studies have used SCI only in patients with a pH of >7. Therapy with SCI was cost-effective and would be useful in resource-poor settings.